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HHS Mentor-Protégé Application

Application Information

The application should be in narrative form and include, at a minimum, the following information in the format shown below:

OSDBU Tracking Number: (The OSDBU Office will provide this number.)

Mentor Firm Information.   Please complete the following:

  • Name of Firm
  • DUNS Number
  • Contact Name
  • Position Title
  • Address
  • Telephone
  • Fax
  • E-Mail
  • Homepage Website Address
  • Current HHS Contract Number(s) with Subcontracting Plan

Protégé Firm Information.   Please complete the following:

  • Name of Firm
  • DUNS Number
  • Contact Name
  • Position Title
  • Address
  • Telephone
  • Fax
  • E-mail
  • Homepage Website Address

Eligibility.   Complete the following:

A small business concern that meets the definition at FAR 19.001, based on its primary NAICS code, is eligible to be a protégé firm. Small Business Administration (SBA) size standards and Regulations/FAR Provision: FAR 19.001; 13 CFR Part 121; 13 CFR 124.1002

  • The protégé firm's primary NAICS code is:
  • The Protégé represents that it is, ___is not a small business concern as defined above.
  • The Protégé represents that it ___is, ___is not a small disadvantaged business concern.
  • If the Protégé represents that it is small disadvantaged business, the Protégé should also identify the category in which its ownership falls: 
    ___African American;
    ___Hispanic American;
    ___Native American (American Indians, Eskimos, Aleuts, or Native Hawaiians);
    ___Asian Pacific (persons with origins from Burma, Thailand, Malaysia, Indonesia, Singapore, Brunei, Japan, China, Taiwan, Laos, Cambodia (Kampuchea), Vietnam, Korea, The Philippines, US Trust Territory of the Pacific Islands (Republic of Palau), Republic of the Marshall Islands, Federated States of Micronesia, the Commonwealth of the Northern Mariana Islands, Guam, Samoa, Hong Kong, Fiji, Tonga, Kiribati, Tuvalu, or Nauru);
    ___Subcontinent Asian (Asian-Indian) American (persons with origins from India Pakistan, Bangladesh, Sri Lanka, Bhutan, the Maldives Islands, or Nepal; or
    ___Individual concern, other than one of the preceding.
  • The Protégé represents that it ___is, ___is not an 8(a) firm.
  • The Protégé represents that it ___is, ___is not a HUBZone small business concern listed, on the date of this representation, on the List of Qualified HUBZone small business concerns maintained by the Small Business Administration.
  • The Protégé represents that it ___is, ___is not a women-owned small business concern.
  • The Protégé represents that it ___is, ___is not a Veteran-owned small business concern
  • The Protégé represents that it ___is, ___is not a Service Disabled Veteran-Owned Small Business concern.

Developmental Assistance Program.  (Prior to submitting the application, the Mentor is encouraged to perform an assessment of the protégé's strengths and weaknesses to assist in establishing a developmental assistance plan.) Describe the developmental program for the protégé firm.Your plan must identify the types of assistance and how this assistance will be provided. The types of developmental assistance a mentor firm can provide to a protégé firm may include:

  1. Management guidance related to -
    1. Financial management
    2. Organizational management
    3. Overall business management/planning
    4. Business development
    5. Technical assistance
  2. Award of subcontracts under HHS or other Federal and commercial contracts on a non competitive basis
  3. Rent-free use of facilities and/or equipment
  4. Temporary assignment of personnel to the protégé firm for the purpose of training;
  5. Property
  6. Loans
  7. Any other types of mutually beneficial assistance
  8. In the table below, provide a list of all the NAICS codes and their descriptions for the areas the mentor will provide developmental assistance to the protégé.
NAICS CodeDescription
  
  

 

Milestones. (Define milestones for providing the identified developmental assistance, and include the requirement for the 18-month report and final report.)

Measurement. (In addition to the developmental assistance plan, provide factors to assess the protégé firm's developmental progress under the program.  Include such things as the criteria for evaluation of the protégé’s developmental success to measure the effectiveness of the relationship including a plan to increase the quality of the protégé firm’s technical capabilities and how the mentor’s assistance will potentially increase contracting and subcontracting opportunities for the protégé firm.)

Estimate of Cost. (Provide a detailed estimate of the total cost of the developmental assistance for the 36 month period.)
Program Participation Term. The Mentor-Protégé Agreement is 36 months from the date of the signature by the OSDBU Director. (These terms will be in the Agreement.)

Potential Subcontracts. (Provide the anticipated dollar value and type of subcontracts that may be awarded to the protégé firm consistent with the extent and nature of mentor firm's business for the next 36 months.)

Mentor Termination Procedures. (These terms will be in the Agreement.) The Mentor shall furnish a written notice to the Protégé, OSDBU and Contracting Officer of the proposed termination, stating the specific reasons for such action, at least 30 business days in advance of the effective date of such proposed termination.

Protégé Termination Procedures. (These terms will be in the Agreement.) The Protégé shall furnish a written notice to the Mentor and OSDBU of the proposed termination, stating the specific reasons for such action, at least 30 business days in advance of the effective date of such proposed termination.

Other Termination Procedures. (Describe any additional procedures for the Mentor and Protégé in this section.  The bullet below will be in the Agreement.)

  • The Mentor and Protégé firms shall have 30 business days to respond to such notice of proposed termination.  The response shall be in writing and submitted to the other party and the OSDBU.

GENERAL TERMS AND CONDITIONS (These terms will be in the Agreement.)

The parties understand that this Agreement is subject to the approval of HHS and is not intended to be a legally binding agreement or vehicle for transfer or commitment of funds or other resources, including a subcontract.

  1. This Agreement shall not constitute, create, or in any way be interpreted as a joint venture, partnership, or formal business organization of any kind
  2. Either party may change its' cognizant point of contact by written notice to the other, with copy to the HHS Program Manager, OSDBU.
  3. All cooperation between the Mentor and the Protégé will be on a nonexclusive basis.  Both parties are entitled to execute similar agreements with other organizations without the notification or approval of either party.
  4. Any resultant subcontract executed between the Mentor and the Protégé must be consistent with the requirements of the Mentor's contract with HHS.
  5. By signing agreement, both parties shall comply with the obligations set forth in clause 352.219-71 of the U.S. Department of Health and Human Services Acquisition Regulation (HHSAR) and all other clauses and provisions governing the program.

Intellectual Property and Proprietary Information. (These terms will be in the Agreement.)
It is specifically understood that disposition of title to and/or rights in and to any intellectual property (including inventions and discoveries, patents, technical data, and copyrights) made or conceived by an employee or representative of the Mentor or Protégé, in the course of or under this Agreement, remains with the initiating party or developer.

The Protégé shall not divulge to any third party any business or confidential information of the Mentor to which the Protégé may be given access by the Mentor in the course of this Agreement for a period of this Agreement.

Other Term and Conditions.  (Describe any additional terms and conditions that apply to the agreement.)


By signing the agreement, both parties give their consent to HHS to make available to the public the contact information included in the “Mentor Firm Information” and “Protégé Firm Information” sections of the application.

Signatures. Duly authorized representatives of the Mentor and Protégé firms are required to sign and date the application.  Titles of the individuals should also be included as shown below:

Mentor

Protégé

 

 


Printed Name

 

 


Printed Name

 

 


Signature

 

 


Signature

 

 


Title

 

 


Title

 

 


Date

 

 


Date

 


Last Updated: 11/23/2010


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